At the heart of every good health system is one that provides good emergency care. Yet, in the past 15 years there has been a 50% increase in the number of people being admitted to hospital in an emergency. This is stressful for patients, and puts a great strain on hospitals’ resources. Last year, the NHS recorded almost six million emergency admissions to hospitals, representing around 70% of all hospital bed days in England and costing in excess of £16bn.

Recent policies, from the Better Care Fund to the New Models of Care and Sustainability and Transformation Programmes, have aimed to reduce the rate of growth in emergency admissions, for example, by concentrating on those that might be ‘avoidable’ through better care out of hospital. But it is not entirely clear what is driving this rising demand. A common line is that emergency admissions have been driven up by the rise in the population of over 65s, as they are the more likely users. However, when we look at the statistics, the number of over 65s has increased by only half the growth rate of emergency admissions. Numerous studies show that demographic trends and population health are able to explain only 40-50% of the total growth.

With the aim of shedding some light onto this puzzle, we planned a new study and gained support from the Health Foundation within the Value for money in the English NHS research initiative. As with many new studies, we tried to be original and look where others haven’t already. We searched for other big changes in the health system that might have a logical relationship with the use of emergency care.  

Without having to look too far, for too long, we found that in the past hospitals have achieved remarkable improvements in the survival rates of their patients by investing in new medical technologies, adopting more effective surgical interventions and implementing new policies on patient safety.  A growing number of patients with acute life-threatening conditions survive after surgery. However, an unintended consequence of this success may be a growing population of patients who are increasingly frail and at high risk of more hospital admissions over time.

We investigated this hypothesis by using a very large dataset including nine million patients with a first hospital admission for an acute event, such as a heart attack or a stroke. We then followed these patients for up to two years from the first acute event, counting the times they were back for an emergency admission for any reason and to any hospital.

We repeated this exercise every year from 2000 to 2009 and found that, in every year, more patients survived their first admission than in the previous year and all surviving patients experienced a greater number of emergency admissions following the first acute event. Our analysis found that patients admitted in hospitals with larger improvements in their survival rates experienced increased numbers of emergency admission following the first acute event.  

When applying this to the total growth in emergency admissions observed between 2000 and 2009 in our sample, we found that improvement in survival accounted for about 37% of the total increase in emergency admissions.

These findings have some interesting implications when applied to the whole population of NHS patients. The survival effect led to an estimated increase of 426,000 emergency admission in 2012 and remained at this higher level thereafter, costing a total of about 1 billion in hospital services every year. This estimate does not include the effect of further improvements in survival which are likely to have occurred after 2009.

Emergency care services of the NHS and many other health systems are coming under significant pressure and there is a need for additional resources to cope with an increasing demand for services. A sizeable part of emergency admissions and their cost can be explained by the success of NHS hospitals in saving more patients with life-threatening conditions.

Finally, policymakers have adopted a series of measures to contain emergency admissions. The measures share the common view that a significant proportion of admissions are avoidable and are often driven by hospitals’ financial incentives and inefficiencies. However, current policies may generate unwanted consequences for the health system, draining resources from virtuous hospitals that are succeeding in saving their patients’ lives.

Dr Mauro Laudicella is a Senior Lecturer in Health Economics in the School of Health Sciences at City, University of London, @MLaudicella.

Comments

Kate Abendstern



This is very interesting and I'd be keen to see a full report if it's available. Understanding the real drivers behind the growth in admissions is a complex issue and any new insight is to be welcomed. A couple of observations / questions:

The summary points out that demographic trends and population health only explain around half the growth in admissions. But your conclusion for this work is that the impact of enhanced survival may be an increase in frail, high risk individuals. Does this cohort not impact on overall population health status (and therefore would already be accounted for)?

Interestingly, this study seems to contradict findings published by the Nuffield Trust in 2010 relating to emergency admissions between 2004 and 2009. While that study concludes the same in respect of the impact of demography on the growth in admissions, it also found that "most of the increase appears to have been in new cases, rather than the same set of individuals being admitted more frequently" (https://www.nuffieldtrust.org.uk/files/2017-01/trends-emergency-admissions-report-web-final.pdf). My understanding of your work is that enhanced survival results in more admissions per individual, which is contradictory to the Nuffield Trust's conclusions.

Finally, I'm interested in the implications of this (assuming the above discrepancy can be explained). Does the study examine the types of conditions for which the increasing number of "surviving" patients are subsequently admitted, or is there no apparent pattern? I'm thinking about the potential implications for the type of secondary prevention services available and the way in which risk stratification protocols work. I'd be interested to see whether there is any more recent analysis that might identify the impact of frailty models on the growth in admissions.




Mauro Laudicella



Hi Kate, thanks for your comments. The full study is available here:

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12755/full

I'll try to address some of your questions. Studies looking at the effect of demographic trends are usually unable to dig into the micro level, such as examining the effect of extending the life expectancy of individuals after an acute episode (e.g. a stroke) and as a result of better care interventions over time. However, a report looking at the demographic effect on utilization of emergency care showed evidence of a strong "period effect" that the authors attributed to demand factors, such as a change in patients’ expectations, or supply factors such as adoption of new technologies. See:

http://eprints.lse.ac.uk/60622/

We do find evidence of a large increase in new admission cases over time similar to other studies. The demographic effect is by far the largest factor in explaining emergency admissions growth, but it leaves a large share of the observed growth unexplained. In our study, we find evidence of an additional factor that can explained such a growth.

Unfortunately, examining the different causes for patient subsequent admissions after the first acute event was beyond the scope of our study. A large part of subsequent admissions might well be unrelated to the first admission. It is difficult to establish direct and indirect relationships between different sequences of admissions in the very heterogeneous basket of all emergency admissions. However, fewer of these subsequent admissions would have occurred, had the patients’ life expectancy be shorter after the first acute event.



Dr Rodney Jones



The above may well explain my observation that the marginal changes in death (all-cause mortality) lead to marginal changes in medical admissions, see http://www.hcaf.biz/2010/Publications_Full.pdf. Any thoughts along those lines?



sylvia humberstone



It is good to see that it is not the elderly living longer that is causing this problem.That is all we hear.The reason for the massive rise in emergency admissions i am sure over the past 15yrs is that the U K population has increased so much and the Gp Surgeries, Hospital,s etc, cannot cope.



Elizabeth Joan Wade



Sylvia Humberstone is partly right. The reason why GP practices and A&E are overwhelmed with patients is because of "unethical medicine" due to the mass medicating of millions of once healthy people made into patients with the deadly statin drug. As Dr Aseem Malhotra rightly says "patients are used as guinea pigs" and statins cause heart attacks not prevent them. Patients go repeatedly to the GP reporting serious side effects but are ignored and told that's to be expected when getting older... More drugs are dished out to deal with the side effects. The likes of Professors Rory Collins and Peter Sever who promote the drug are in the pocket of Big Pharma. Yes, it will be the biggest medical scandal in the history of medicine. Another reason for the big rise of patients attending A&E, especially on Fridays and Saturdays, is the abuse of alcohol. It's time people that drink excessively are charged for the time care they receive. And as Dr Malhotra also rightly said this is why the NHS is on its knees. In 2008 I almost died from a life-threatening statin-induced adverse drug reaction that's been covered-up by the NHS ever since. The NHS doesn't need more money it needs to get its house in order.



Mauro Laudicella



Hi Rod. Thanks for your interest in this piece of research. We are aware that this topic has received a large number of contributions by many authors, but unfortunately we were allowed to include only a limited number of references in our manuscript. It could be helpful if you could mention the specific references that you see relevant in your list, so that we can consider them in future works.



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